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HomeMy WebLinkAbout0829A WORKERS'COMPENSA7[ONDECLARATION 76A663 APPLICATION FOR ELECTRICAL PERMIT � {� � CE806G(290) � 1 hereby afHrm that I have a certificate ot consent to self COUNTY OF LOS ANGELES BUILDING AND SAFETY L� insure,or a certificate ol Workers'Compensation Insurance,or � � - - ' � a cettifled copy thereof(Sec.38�0,Lab.C.) T - � �P81=6249�4 FPeeR�Ont indemn�ty FORAPPLICANTTOFILLIN J09 g�dg - U �t$-�J2��J � Polfcy . ompany qDDRE55 NeW Residential Bidgs.&PoOIS EACH NO. FEE � � CertiCed copy is hereby furnished.. 9/30/82 1&2•Family,5q.Ft. s — $ LOCALITY TR#41305 - Di amond Bar Q Certified co Mutti-family Sq.F.t. 4L�,]3 — '4 T - . . � py u filed with the tounty 6uilding inspection Residential Swimming Pools CROSS ST tde7partment. OWNER OR � 11 ZO HL ; FIFM NAME Presle- Co. Date�Applicant� �Pp FlPctric putlets:Rec.�Light�Sw.� � ,60� �20 - 1'Z. � MAIL� , � F��st zo ADDRESS 4600.Com US DP. CERTIFICATE OC EREMPTION FROM WORKERS' Total No.20 � Additional c�T�{ew ort Bch.� Cd Te�No.540-0500 �. '� . � COMPGNSATION INSURANCE � . P�AN CtiECK . a Cfhis sectian need not be completed if thE WO��C 1t1VOIV¢d AVPLICANT V _ by the permit is for one hundred dollars (SI00)or�ess.) Lighting Fixtures First 20 qoORESS ¢ � Additional I certify that in the perforinance of the work for which this F zed Appliances Not Over 1 HP CITY - Tel No. � � U �petmit is issued,1 shall not empioy any person in any tnanner � PEHMIT �y so as to beco'me sub)eet to the Workers'CompensaHon Laws. . Range_Heater_D.W. � APPLICaNT y - - - - ' � - Oven-_Dryer�(W,M.� _ �� ADDRESS � N "� ' � Top _FAU X W.H. � Date � Appiieant , Hood_Fan _Other�G: : Ope �r � � ��TY Pomona;Cd.91769ra�No.627-0936 . _ — NOTICE TO APPLICANT:If,after making this Cert[ficate of - Disp. _Room Air Cond� L�C NSE OR . _ — . _ � F.xemption, -you should become subject to the Workers' . REG.NUMBER Cles� Compensation provisions of the Labor Code,you must forth- power Apperatu5&Wrg¢Appliances DISTiiICT NO, PROCESSE BY with comply with such provisions or this permit shall be Size&Type HP,KW,KVA,or KVA � deemed revoked. � . � � l(�/ ("��� � . � Up to 1 Incl.� � - � . . -: . � ' FINAL . . , LTC£.NSED CONTRACTORS UEC4ARATION �Over 1 to 101nc1. DATE �d/� �a . VALI�ATION Over 10 to 50 Incl. - . � 1 hereby affirm that I am licensed under provisions of Chapter � Over 50 to 700 Inc. eY AL � _ 9 (commencing with Section 7000)of Divislon 3 of�he Busi• Over 100 . . ness and Professions.Code;and my license is in lull force and . � - � etfect. � , � Services � � � �- � � � Lic ns� Numbet �1533�$ Lic. less C-10 0-200 Amp.Under 600 V � ._ . ' � g'Cf' McG e ec tc, �nc. � 201-0000 Amp.Under 600 V Contrector pate 11 ZOIHL' - Over 1000 Amp,or Over 600 V . . , . ... � }iOME OWNER-BUILDLR DECLARATION Temp.Power Pole&Appurtenances� . . - - � . � 1 hereby atfirm that I am exempt from the Contractor's Sign with One Branch Circuit- � � � � � ' �, - - � - - � Licen'se Law fo�the following reason(Sedion 7031.5,Busi• �+dditional Sign Braneh Circuits � _ � �0829A ness and Rofessions Code): , , . � Miu.Conduits&Condueton � � � I,as owner of the propmty,witl do the work and the Otber ISee Comp�ete Fee Sehedule)— ' � � ��.� �����? s[Ncture is not intended or oifered fot sale (Sectfon � � . ' � 7044,Business and Prohssions Code). I�° � �l�-J 3 � CONSTRUCTION LENDING AQENCY ��. 1 hereby affirm that there is a construction tending egency �� � � � •�^ � �i��:.J J u for the performance of the work for which tFis permit is pERMIT FEE (Sub-7ota1) � :. issued(Sec.]097,c��.c.�. . . _ �135. 3� � ' , - � - � �,�5�Fj.' � Lender's Name� . pLAN CHECKING FEE fOne-Fourth Permit Fee1 - � � � . Lender's Address ' pERMIT ISSUING FEE � . $, Q �. � . � I ceriity thet I have read this application and state ihat the TOTAL FEE � �14t�. 3 - � - � above information is correct.[agree to comD�Y K'�th ali County � � � - � � � - ordinances and State laws regulaling Flectricat wiring, and . � hereby authorize representatives of thia County to enter upon ' - �- . � - ' �the above-mentioned property for insptction purposes. � SEE'REVERSE FOR ERPLANATORY LANGUAGE � � 11�20�81 � Signature Permittee- Date � . � ' �.. . . � . I --- --i i .....�. ...I .,'... 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